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Full text of "An inaugural thesis on jaundice : containing observations on the liver, and some of its diseases ; submitted to the examination of the Revd. John Ewing, S.T.P Provost, the trustees and medical faculty of the University of Pennsylvania ; on the 6th day of June, 1799, for the degree of Doctor of Medicine"

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AN 

INAUGURAL THESIS 

ON 

JAUNDICE;' 

CONTAINING 

OBSERVATIONS ON THE LIVER, 

AND 

SOME OF ITS DISEASES. 

SUBMITTED TO THE EXAMINATION 

or THE 

REV. JOHN EWING, S. T. P. PROVOST, 

THE TRUSTEES AND MEDICAL FACULTY 

OF THE UNIVERSITY OF PENNSYLVANIA ; 

ON THE 6th DAY OF JUNE, 1799, 
FOR THE DEGREE OF DOCTOR OF MEDICINE, 

EY 

TAMES NORCOM, OF N. CAROLINA, 

HONORARY MEMBER OF THE PHILADELPHIA 
MEDICAL AND CHEMICAL SOCIETIES. 



Phozbe. fave, nevus templa tua ingr'sdltur. 



P H JL AD E LPHUi 

V R I N TED B Y J AMES CARE V, 

FORMATHJ&W < 



TO 

CASPER WISTAR, M. D. 

ADJUNCT PROFESSOR OF ANATOMY, 
SURGERY AND MIDWIFERY, 

IN THE 

UNIVERSITY OF PENNSYLVANIA. 






X HIS differtation is refpectfully infcribed, as 
a (mall tribute of gratitude and cfteem, for the 
important and difintereded fervices, which he has 
been picked to render his 

Much obliged friend and 

Very devoted fervant, 

JAMES NORCOM. 



INTRODUCTION. 



XTL 



PROBATIONARY thefts being neceflary to 
obtain a degree in medicine; I have ventured in the 
fubfequent pages to lay before the public a few 
hafliy obfervations on the fubjecl: of jaundice— 
This I have done, not from a confcioufnefs of the 
utility of fuch a practice, not with a view to di- 
vulge or promulgate any favourite hypothefis of 
my own, nor yet with an intention to abet, or op- 
pofe the affeverations of others ; but in obedience 
only to that law, by which it is exacted. 

I once indulged myfclf in the agreeable expecta- 
tion, of inftituting a feries of experiments, on feme 
indigenous vegetable production ; but have to re- 
gret, that the want of talents, time, and oppor- 
tunity, qualifications indifpenfable to the execution 
of fuch a tafk, has rendered it wholly imprac- 
ticable. 

In every inaugural effay- which hath come under 
my examination, it has been cuftomary to quote the 
authority of different writers, andtofpecifybypar- 

A 2 



(iv) 

ticnlar references, the work, or parts of the work, 
from which fuch quotations have been taken — In 
the following meets, I mall not introduce fuch 
quotations or references at all, except, what I may- 
have occafion to mention in the text or body of the 
compontion, and hope to be excufed, mould I in 
any place be found adopting opinions which have 
not been generally acknowledged, without fpecial 
reference to the authors of their exiftence. Of 
this pardon, I fhall be the more confident, if gen- 
tlemen recollect, that the majority of thefej are 
mere compilations, and that the more or lefs judi- 
cious his feieaion, the greater or lefs will be the 
merit of the author's performance. 

In thus deviating, from a long eftablifhed 
cuftom, I do not intend to deny my obliga- 
tions to authors who haye treated on the fubjecx 
about to be coniidered— The fads upon which 
many of the following obfervations are founded, 
are contained in the writings of Morgagni, 
Bonetus, Schenkius, Monroe, Boerhaave and Hoff- 
man— I am not fenfible of having taken any thing 
for granted, which experiment and the common 
obfervations of mankind have not amply illuflrated 
—Without prepofletfion in favour of any parti- 
cula r opinion, and with a predilection to the autho- 
rity of none, I have read attentively the works of 
thofe, who have written profeffedly on my fubjett, 
and have been guided in my arrangement, by the 
dictates of my own understanding. 



(v) 

I am aware that I have to encounter the ordeal 
of public opinion, though totally unqualified for 
fuch a trial ; and coming forward in a literary 
world under many difadvantages, more efpecially 
in a publication like the prefent, executed with fo 
much precipitation and hurry, no one will expect 
to find me invulnerable by the fhafts of criticifm — 
I therefore fubmit it with the utmoft diffidence, 
foliciting fuch allowances from an indulgent 
public, as its numerous inaccuracies fo egregioufly 
require. 



HISTORY OF THE DISEASE. 



Ti 



HE difeafe which I have fele&ed from the nofological 
catalogue, as the fubjecl: of enquiry on the prefent occafion, 
is one, which has been long known among medical pra£U- 
tioners, by the name of Jaundice. It is defcribed in books 
of antient authority by a variety of appellations, fuch 
as Morbus Acuatus, Icretus, Aurigo, Icterus, Morbus Regius, 
and many others equally arbitrary and uninterefting. It is a 
difeafe, which is probably coeval with fome of the moft an- 
tiquated of human maladies, and is common in all warm 
climates — Perfons of every age, fex, and conftitution, are 
alike fubject to its invafion, it occurs ofteneft in the bilious 
temperament, or in thofe who are fubje£fc to hepatic and 
towel complaints, and is faid to appear principally in the 
feafcns in which thofe complaints are mod prevalent. 
Such as have once had the difeafe, are liable to frequent 
returns of it. 

Jaundice confift? in too great a quantity of the matter 
ef bile in the blood, exhibiting a yellownefs of different de- 
grees of intenfity, and more or lefs diffufed, on the exter- 
nal furface of the body. It is brought on by caufes, which 
prevent the excretion of bile, after it is feparated from 
the blood j and poilibly, by fome inexplicable changes 
he circulation, effected by caufes to be hereafter enume- 



( 8 ) 

rated. People in common circumflances, often go about 
with the difeafe upon them, without experiencing any 
great inconvenience, and tranfadt the ordinary bufinefs of 
life, particularly, where no great mufcular exertion, is 
required. The duration of Jaundice is extremely uncer- 
tain: in fome it will difappear in a few days; in others it 
will continue for many months, nay even years, without 
producing any confiderable conftitutional injury. 

SYMPTOMS. 

Antecedent to the appearance of Jaundice, the patient is 
often heard to complain, of pain fometimes acute, but of- 
tener obtufe, in the right hypochondrium, or in the epigaf- 
tric region juft below the fcrobiculus cordis, at a point cor- 
refp'onding to the entrance of the biliary and pancreatic 
duds, into the dOodenum. It is often preceded by naufea, 
ficknefs, anxiety, a difpofition to faint, with figns of languor 
and univerfal debility, which frequently continue fome time 
before the i&eritious colour makes its appearance upon the 
external fuperficies of the body. But it not unfrcquently 
happens that the accefhon of the difeafe is fudden, and with- 
out any premonitory fymptom whatever. There is generally 
a fenfe of weight, and tenfion, about the hepatic region, 
with a pain, which is commenly referred to the ftomacn, 
and which is cither continual and obtufe, or intermitting 
and very feverc ; Jaffitudc cf body, dejeclion of mind, drcw- 
finefs, difinclination to motion, and unrefrefhing fleep, are 
its conftant attendants. The tunicx albuginerc cf the eyes, 
are the parts where yellownefs, generally, is firft perceptible, 
after which, the nails, and at length the whole furface of tha> 
•body, acquires an uncommonly yellow colour; this yellow- 
nefs in fome cafes has been known to pervade every part cf 



(9) 

the body, internal, as well as external, even the very bones 
and cartilages themfelves, have been found deeply impreg- 
nated with bile. 

The colour of the fkin in Jaundice, correfponds exactly 
with that, which may be produced, by a mixture of bile with 
a certain proportion of water, giving a pale yellow fnade, bu'; 
novv and then tending to that of a deep yellow, according 
as the bile is more or lefs diluted, with the watery part of 
the blood. The urine being faturated with biliary matter 
aflumes a yellowifh red, tinging a piece of paper, or linen, 
dipt in it, of a durable faffron colour. The faliva, which 
in a ftate of health is perfectly infipid, becomes fenfibly bit- 
ter, which frequently gives the patient an idea, while eating, 
that his food is bitter. 

Thefe fymptoms are often accompanied by thirft, want 
of appetite, great irritability of ftomach, and frequent fits of 
vomiting ; and if the difeafe continues two or three days, 
the patient becomes confiderably emaciated. 

Such 2S happen to be afflicted with this complaint, fufrer 
exquifite torment, from flatulency, dyfpepfia, heart-burn, : 
hiccough, and acid eructations \ twilling and rumbling ot 
the bowels, with extreme pain. The fceces are paie, rough 
and irregular, and at laft aflume an alh or clay colour, nor 
have they their ufual feculent odour. The bowels are for 
the rncft part conftipated, and the excrements, when voided, 
have often an uncommonly putrid fmell. During the whole 
courfe of the difeafe, more cr lefs fever attends, with alternate 
chills and flufhes, and fometimes a delirium with partial fpafrns, 
or univerfal convulfion. The fever is cften very violent, but 
feldom ccmes en until many of the other fymptoms have con* 

B 



/ 



( TO) 

tinned fome time. The puife is variable, generally quicker 
and ftronger than natural; fometimes, however, it is pre- 
ternaturally flow and hard. 

As the clifeafe advances, refpiration becomes more and 
more difficult, frith palpitations of the heart, uneafinefs and 
anxiety about the prcecordia. — The languor and laflitude go 
on increafing, with dullnefs and a degree of ftupidity, fome- 
times bordering on fatuity, until the whole body is tinged of 
a yellow hue, which, in fome few inftances, has approached 
fo near to black, as to have given rife to the ridiculous 
term, Black Jaundice. 

Objects viewed by perfons in Jaundice, fometimes appear 
indiscriminately of a yellow colour, except fuch as are blue* 
which, according to fome authors, are often miftaken for 
green — An itching, and drynefs of the (kin, often teaze the 
patient ; while hemorrhages from the nofe, gums and 
inteftines, affift in aggrandizing the lift of his diftrsffes— a 
diarrhoea rarely attends, but when it does, although accom- 
panied with profufe difcharges by urine and perfpiration, 
is commonly deemed a falutary fymptorn. 

Obftruaions and dropfjr, finally come on; the patient 
falls into a fhte of extreme debility, and after fome hours of 
intolerable pain, appears fuddenly relieved, and fmks, as it 
were imperceptibly, from a ftate of celeftial tranquility, into 
in eyerlafting (lumber— The fatal termination is net always 
' thi the patient fometimes feels, in the laft moments 

cf departing life, the moll excruciating mifery— Very differ- 
ent indeed, is the face of things, when the difeafe is about to 
end favourably— the patient, in this cafe, is not much re- 
el G aatinues to go about, has fewer of the fymptorn?, 



f.H ) 

and thofe lefs violent, his fpirks continue good, and his di- 
geftion not much impaired, until, by his own cautious ma- 
nagement, by the uncontrolled exertions of nature, or by the 
interpofition of proper medical aid, the difeafe is entirely 
fubdued, and he reftored to perfect health. 

Before I proceed to the next divifion of my fufeje£l, it will 
Rot be amifs, to premiie a few remarks, on the nature, fecre- 
tion, and ufs, of the 

BILE. 

The bile is a fluid of a grcenifli yellow colour, an interrfely 
bitter tafte, of anoleagenous vifcidity, having a peculiar aro- 
matic odour, a little more thick in its confidence than milk, 
and rather more yifqid. 

It has been called an animal foap, but I do not be- 
lieve with fufficient accuracy, becaufe, the analogy be- 
tween them is by no means fo extenfive, as has been fanci- 
fully imagined— Chemifts, to be fure, have obtained from it 
an oil, and an alkali, but admitting the formal exiftence of 
thefe two fubftances in the bile (which I very much doubt), 
it remains yet to prove, that they exift in fuch a ftate of com- 
bination, as to conftitute a true foap.— The milk, we are 
taught by chemiftry, is capable of affording a fixed alkali, 
and we are certain, that oil is prefent in it, in great abun- 
dance, yet, no one will pretend to fay, that it is a foap, oil 
that account ; and we might with as much reafon, and pro- 
priety, give the epithet to one, as the other— The bile too 
has, in the hands of the dyer, fucceeded in taking out (tains 
and blotches, from clothes, but, reaified fpirit and the fixed 
alkalies are, in fuch cafes, equally fuccefsful— It is kid to 

B 2 



( 12 ) 

have anfwered further, the purpofes of the artift, as a me- 
dium of union, for oil and water, in the art of varnifhing ; 
and the phyfiologift has been content to fuppofe, that it 
might have fomc analogous operation, upon the oily, and 
aqueous parts of our aliment, in the primae vise-, but it mould 
be remembered, that there are other fubftances which will 
do the fame thing, as animal glues, the yolk of an egg, 
vegetable gums, mucilages, &c. and with what propriety, 
or judgment, any of thefe fubftances could be called fuaps, 
the intelligent reader will be at no lofs to determine. 

In order to obtain further information, on this fubject, I 
made a few fimple experiments ; the refults of which, with 
deference to the high authority of Fourcroy, Cadet, Chapjal, 
and others equal in celebrity, I will relate for the benefit of 
xny readers— i ft. The bile, unlike the fubftance called foap, 
is not mifcible with oil, except by the affinity of an interme- 
dium — 2dly. No neutral fait is obtained by treating the bile 
with acids— 3 ly. That fubftance feparated from bile by the 
addition of an acid is foluble in, and mifcible with water— • 
Thefe facts, in my opinion, go very far in proving that the 
appellation of foap, as applied to the bile, is an unjuft one *, 
that fuch a conclufion will be warranted or confirmed, by 
future and more convincing experiments, I (hall not attempt 
to affert. 

The bile, from numberlefs experiments which have been 
inftitured and performed on it, appears to be compofed of a 
ferous or watery part,— a coagulable putrifiable matter, 
analogous to the coagulable lymph of the blood, and a fub- 
tile aromatic principle, in which, befides its peculiar odour, 
its colouring matter and bitternefo are thought to refide- 
I mall not add to the many uninterefting difputes, which 
have been agitated about the origin and formation of it. 



I 

( H ) 

eonflltuent parts •, and it would only be making an unneeefTary 
digrefiion to ftate the current opinions on the fubject. 

Subjected to the torture of fire, the bile yields an empy- 
reumatic refmous oil, the mineral alkali, a fmall quantity of 
iron, and phofphorated lime — it is alfo faid to contain a 
large quantity of carbonic acid or fixed air, united to 
the mineral, alkali which is contained in it, and this 
has been found more efpecially the cafe, with thofe 
Concretions, which are often derived from it •, hence, a fuf- 
picion has arifen, that this latent air, might increafe the at- 
traction or cohefion of the other parts of the bile, and thus con- 
tribute to the formation of calculi : on the probability of thia 
theorylam totally unprepared eventoventure an opinion —The 
bile appears to be a gelatinous compound, intimately united 
in its parts, capable of coagulation by acids, and fufceptible 
of greater fluidity by being combined with alkalies •, its coa- 
gulability is diminifhed by putrefaction, and its coagulum is 
fo clofely blended with the other parts of it, that it cannot 
be obtained free from them, except by its own proper folvent. 

From experiments, which appear to have been faithfully 
made, and candidly related, it is concluded, that the prin- 
ciple of bitternefs in the bile (whatever it be) refills the 
effecls of putrefaaios j while the vilcid coagulable matter, 
more readily putrefies than other fubftanccs. 

The bile which is found in the gall-bladder, differ* 
from the newly fecreted bile, in being more vifcid, yellow, 
and bitter : this does not arife fo much from a difference 
of origin, nature, or fecretion, .as from confinement and 
ftagnation in the gall-bladder, where by the abforption of its 
more attenuated and limpid parts, it undergoes this remark- 



( 14 ) 

able change. The conflituent r)rincip!es of the cyftic and 
hepatic bile are the fame, and the oniy way in which they 
differ, is in the proportion of their component parts. 

The apparatus of vcilels, appropriated to the fecretion of. 
bile, is curious and interefting. The vifcus which is princi- 
pally concerned in this noble operation, is the liver, a gland. 
of the conglomerate kind, of a dufky red colour, deftined to 
refine and depurate the vital mafs •, while it is at the fame. 
time fubfervient, to one of the mod wonderful and indifpenf- 
able procefTes in the animal ceconomy : viz. digeflion. 

The liver, the largeft gland in the body, is fituated in that 
part of the abdominal cavity, called by anatomifts, the right 
hypochondrium, which it often completely fills*, it frequently 
occupies a portion of the epigaftric, and is fometimes of 
fuch fize, as to extend a confiderable diftance into the left 
hypochondriac region ; it is covered by a proper membrane 
•f its own, and a common one from the peritoneum j — it is 
fixed in its place, with its convex furface correfponding to 
the concavity of the diaphragm, by ligaments, derived 
chiefly from the peritoneum, and attached to various parts 
of the abdominal parietc:, called lateral, coronary, um- 
bilical, fufpenfory, &c. The liver, in a natural and healthy 
(late, is entirely vafcular, compofed of the ramifications of 
the vena portarum, hepatic veins, and hepatic artery, the 
fecretory and excretory duds, befides which, enter into its 
comooution, in common with all other parts of the body, 
nerves, and lymphatic vefTels. 

The fecretion of bile is very remarkable, for unlike the 
ether fecreted fluids of the body, it is not feparated from 
entire arterial blood, but from that which is collected from 
the vifpera of the abdomen, in one large veflelj known by 



( *s ) 

the name of vena portarum, a vein, performing in a great 
mcafure the office of an artery, which ramifies every where 
through the fubftaiice of the liver, and fends off the biliary 
fluid from its capillary or extreme branches, in a fet of fe- 
cretory veffels, called pori biliarii, which uniting in their 
courfe cut of the liver, form larger and larger trunks, until 
they make up a veflel of confiderable fize, diftinguifhed by 
the name of hepatic duct, through which and the ductus 
Communis choledochus, the bile is perpetually diftilling, into 
the duodenum, except by fome fpafmodic affection or morbid 
diftenfion of that intefline, or fome obilrudtion if§ the com- 
mon duct, its admiflion is prevented ; when, it paffes in a 
retrograde direction, through the cyftic duct into the gall- 
bladder, where it is called cyftic, in contradistinction to tiie 
other, which has acquired the name of hepatic bile. 

/The gall-bladder is a fmall pyriform bag, which lies in a 
depredion on the concave furface of the liver, at the an- 
terior part, and right fide of its great lobe, with its fundus 
or large extremity pointing downwards. It is compofed 
cf two principal coats, the internal of which is vinous, 
like the villous coat cf the inteflines ; the fecond is fup- 
pofed to be mufcular; it has alfo, a partial covering 
from the peritoneum ; it terminates obliquely upwards and 
inwards, in a fmall twilled neck, continued into a mem- 
branous dud, called cyftic, which joining with the hepatic, 
forms the ductus communis choledochus. This refervoir does 
not feem to exift as immediately necefTary to the fecretion of 
bile, nor as indifpenfable in the procefs of digeflion, but as a 
receptacle, provided by nature, to contain any fuperfluous 
quantity of bile, that might accidentally be feparated. This 
opinion is rendered probable, by directions, which (hew the 
cyftic du& to have been completely obliterated, and the gall- 



( iM 

bladder full of concretions, when no diforder of the liver, 
or irregularity in the function of digeftion, had been taken, 
notice of before death. That bile, which is depofited in the 
gall-bladder, by its flagnation acquires fuch acrimony, as 
to excite a contraction of its mufcular coat, which propels it 
into the duodenum, except by fome mechanical power, at 
the diftenfion of the ftomach, vomiting, violent -ts of cough- 
jig, &c. it be previoufly evacuated. "Whether this difchargc 
is accidental merely, or whether it anfvvers any valuable 
purpofes in the ceconomy, phyfiologifts are not agreed. 

The fecretion of bile is a fubjedt enveloped in much ob- 
fcurity ; the ufe of it, however, is fomewhat better under- 
flood — From the effects of an impeded or prevented fecre- 
tion of bile on the conflitution, it is fuppofed that the 
biliary fecretion, is intended to obviate a putrefactive ten- 
dency of the blood — And when we confider, that nature ufes 
venous bfood for it, and that too, which is collected from, 
parts where procefTes of a fermentative kind, are often going 
on ; added to this, the tardy circulation of the blood, from 
which bile is derived ; that whatever has a tendency to in- 
creafe putrefaction out of the body, augments the fecretion, 
of bile i that in the higheft grades of bilious fever, in which 
the tendency of the fyftem to putrefaction is fo great, a re- 
dundance of bile fo often occurs ; and that the fecretion is 
increafed from flarving in which fymptoms of putrefcence 
are fo conflantly obferved ; we cannot help believing, there 
is fome foundation for this opinion — Whether this increafed 
biliary fecretion, be owing to fome change produced in the 
blood, which facilitates its converfion into bile ; or an effort 
of the fyftem to refill the effects of caufes, inducing putre- 
faction, is not clearly afcertained. But we uniformly find 



( I? ) 

it to attend die long continuance of hot weather, mewing 
itfelf during the prevalence of thofe fevers, which prevail in 
the fumraer and autumnal months — It is acknowledged by 
mod writers, that when remittent fevers continue until the 
commencement of cold weather, they lofe their malignity, 
and tKeir bilious fymptoms vanilh— This remark feems 
to {hew, that the redundancy of bile which appears in 
thofe fevers called bilious, is more the effect of a particular 
ftate cf the blood in the hot feafon, than of the difeafe which 
it accompanies — And how often muft it have happened to 
practitioners, to obfervc fevers of the remittent and inter- 
mittent type, in every feafon of the year, in which there 
occurred no one circumflance that would lead them to ful- 
.pect a redundance of bile ; nor will they deny having feen, 
profufe and unnatural difcharges of bile, with which little 
or no general fever appeared, as in cholera morbus, bilious 
diarrhoea, &c. — But to return. 

The bile is a fubftance admirably adapted to the ammUa- 
tion of the many heterogeneous compounds with which 
meets in the firft paffages— The glutinous part of it, ferves 
as a medium of union, for the aqueous and oily parts of our 
aliments— By its bitter and antifeptic qualities, it obviates or 
correas their afcefcent, and putrefadive tendency— And by 
its gentle ftimulus, it imparts vigour to the interlines, keeps 
up their periftaltic adion, and thus promotes and facilitates 
the cxpulfion of the fxces— That thefe are the effects of 
bile in the inteftinal canal, is evinced, by what happens from 
an excefs, or total privation of it. 

CAUSES. 

Jaundice, mod common:/ z n an • 

tj . •-■ of bile ' 



( i8 J 

either in the hepatic duel, fome of its branches, or in the 
dutlus communis choledoclius ; in both cafes, the liver be- 
comes difeafed from congsftion, and the bile, if it continues 
to be fecreted, is either taken' up by the patulous mouths of 
the abforbents, or regurgitates directly through the branches 
of the hepatic veins — An impeded or depraved fecretion of 
bile, I believe, feldom, if ever, gives rife to Jaundice — on 
the contrary, it is generally owing to an obftru£tion, to its 
excretion, after it has been duely and naturally fecerned 
by the liver ; by which means, it is admitted into the 
circulation, and communicates to the fluids fecreted 
from the blood, its colour, bitternefs, and other fcnfible 
qualities. 

The bile, I faid, might return into the circulation after its 
fecretion in the liver, by abforption and regurgitation. 

Under the head of abforption, I prefume, little need be 
faid : for it is-univerfally allowed, that there exift numerous 
lymphatic veffels, in the liver, gall-bladder and biliary duds, 
which, in a natural and found (late of the parts, only take 
awaj the pure watery part of the bile, and perhaps, a 
fluid which is continually exhaling into their cavities, to 
lubricate and defend them from its acrimony— But when 
the excretion is prohibited, either in confequence of 
the ftimulus of diftehfion, or from fome quality in the bile, 
it is abforbed by the lymphatics, and unlefs its efflux into 
the inteftiwes be fpeedily promoted, the whole volume of 
blood la impregnated with it. 

A great deal has been faid to prove, that a regurgitation 
of bile never takes place, and from the experiments and cb- 
fervations of doctor Monroe of Edinburgh, it would feem, 



( 19 ) 

that It rarely dees ; but that it fometimes happens, I am pa-- 
fuaded by the following reafons : I. A common injection 
paries readily, and eafily, from the hepatic duel into the 
hepatic veins, and vena cava. 2. Having proved the psf- 
fage pervious, by injection, it is plain, that when the gall- 
bladder is much diitended, and an infuperable obftructicn 
exilts in the ductus communis choledochus, the bile by the 
immenfe preflure to which it is fubjected from the contrac- 
tion of the diaphragm and abdominal mufcles, in the a£t or 
vomiting, or during any other violent exertion of the body, 
will pafs again through the fecretory du£h, to the fountain 
from which it originally fprang— nor is there any difficulty 
in understanding the facility, with which this may happen 5 
for, as rhe blood is continually moving forward in the vena 
portarum and hepatic veins, towards the heart, the refiftance 
muft be greater at the obdrucYion in the duct, than it can be 
at the veins where the biliary pores take their rife. And, 
laftly, how can we account, for the fudden relief which 
violent fits of vomiting give, when no calculus is voided, and 
no bile evacuated, but by recurring to the daftrine of regur- 
gitation. 

Inflammation, fuppuratlon, and fchirrous tumors of the 
liver, have been ranked among the caufes which produce 
Jaundice ; but as there are upon record fo many cafes of in- 
flamed, and obftruded liver, in which the difeafe has never 
appeared, it may be jult'.y doubted whether fuch affections, 
eiclufive of forne irregularity or obftruetion in the biliary 
du6ts, are capable of producing it at all. 

It would furely be of the nrft importance to knew, whether 
this be really true. Here, then a queftion of primary mag- 
nitude, obtrudes itfelf upon our examination, does, or does 
juyXy the bile exift formally in the blcod ? 



( 20 ) 

There certainly is no doubt, that the blood contains the 
materials necefTary to the formation of bile \ but how, or in 
what! manner, they exifl: in it ; is a queftion, for the folution 
of which, in my humble opinion, teftimony is yet wanting. 
If it abfolutely exifl: formed in the circulating mixture, 
and be perceptible to the fenfes m the blood, we have 
reafon to admit, that affections of the liver, diminilh- 
ing or preventing the fecref ion of bile, may produce genuine 
Jaundice. But if, on the other hand, nothing can be detected 
in healthy blood, ' which has any fimilitude to bile j and if, it 
be merely a product of the blood, compofed, and feperated 
by the liver (which I believe to be the fad), fuch an opinion 
is utterly inadmiflible. 

Neither the yellow colour of the bile, nor its bittcrnefs, is 
ever to be obferved in the blood of a healthy perfon, and I 
can fee rio good reafon for fuppofing, that it is difengaged 
from the blood in any other manner., than by fome fecret, and 
unintelligible procefs going on in the liver. The analogy of 
other fecretions feems alio to invalidate this notion— we do not 
had urine abounding in the blood of thofe who fuffer from a 
luppreffion of that fecretion— nor do we find the blood of caf- 
trated animals abounding with femen. The milk is probably 
a f:creted fluid, and is to be obferved in the female fex only 
—now if it exifted in the blood formed, why mould we not 
fee it abound in the blood of the male, or that of the female, 
' in the ab'fence of la&ation. The ftruaure of the glands* 
[tine^d to the feparation of the fecretions ; is ^o evidently 
liar that, I could as fcon expect to obtain urine, or femen 
om the blood of a healthy animal by a chemical operation, 
as the bile : and furely the moft enthufiaftic theerift, will 
I for a moment think, that all the fecretions exifl: formally 
I. If fuch were the cafe, what an odd compofi- 
tion would this blood be. If the bile exifted already formed 



( 21 ) 

in the blood, the fepwration of it being interrupted by ob- 
{Iructions or other diforders of the liver, remaining with its 
impurities in the blood, at the fame time that more is con- 
ftantly generating ; the circulation would foonbe furcharged, 
and the whole animal fabric degenerate into a mafs of bile. 
Befides, many variations of the liver, with refpecT: to fize, 
figure, &c. have been obferved by anatomifts in which the 
general health of the perfon fo affected— was not in the lead 
altered. 

But, it has been declared, under the fanclion of experiment, 
that bile exifts formallyintheblood. Mr.Fourcroy, we are told, 
gave, in the year ninety, a memoir in the Annals of Chemiftry 
containing experiments, which were thought to prove the 
formal exiftence of bile in the blood. Far be it from me to 
fay that it is fo, but, I muft.think, that this ingenious ex- 
perimentalift was miftaken. Not having been fo fortunate 
as to fee the memoir containing Mr. Fourcroy's experiments, 
I was induced to make feveral myfelf 5 and in no one in- 
ftance was I able to detect any thing in the blood which had 
the fmalleft refemblance to bile. 

Although, I cannot completely affent to this belief, I think 
it highly probable, that the conftituent principles of the bile, 
may be prefent in fuch a fiatc in the blood, as to render a 
feparation of it poffible, by certain changes in the circulation, 
without the inftrumentatrry of the liver. This opinion re- 
ceives fome fupport, from the ob* r ervations of many authors, 
which demonftrate, beyond a doubt, the exiftence of Jaun- 
dice, when the liver and its appendages, were in perfed 
health, which may be more fatisfacTborily accounted for, by 
fuch an hypothecs, than by imagining that the bile meafures 
its way back again into the circulation. I allow, that in 



( 22 ) 

many cates of dhTeclion after death froth this difcafe, many 
morbid phenomena have been obferved in the liver ; but, in 
fuch cafes it had continued a gre2t while, which, with 
other collateral con federations, feems to render it probable 
that the affection cf the liver was the effect, and not the 
caufe of the difeafe : moreover, I believe that difeafes of the 
liver and obitructio.ns of the biliary ducts, are often recipro- 
cally dependant upon each other ; an inflammation in the 
liver may give origin to cbftruction in the ducts feveral 
Ways; arid who will be fo precipitate or ram as to deny, 
the exiftence of hepatitis, and other difeafes of the liver,. 
ariGng from diforders in the biliary duels. 

Doctor Marcard, I cbferve, in the Edinburgh Medical 
Commentaries by doctor Duncan, fome time ago broached 
an opinion entirely new j I wifh I were warranted in adding, 
that it was as ingenious as new, but candour forbids the af- 
fertion. He undertakes to prove that fecreted bile, in cafe 
of any ftoppage in the duels, tranfud^s through the coats of 
the gall-bladder, into the cavity of the abdomen, and then- 
enters the circulation, by abforption. The bile (he fays) 
is of a very penetrating nature, and the gall-bladder, like 
evsry other membrane of the kind, is porous. In order to 
fubftantiate his theory, he adduces many fads from morbid 
directions, where a confiderable quantity of bile was found 
on the outfide of the gall-bladder, which plainly appeared to 
have oozed through it — he alfo mentions, the cafe of a foldier 
wounded in the right fide, who died on the i;rh day after 
the accident, but, who was, previous to death, afflicted with 
a partial Jaundice — Upon dhTe&ion he was found to have a 
fmall wound in the fundus of the gall-bladder, through which 
the bile had pafled into the cavity of the abdomen — This 
opinion, like the doctrine of Hippocrates with regard 



( 23 ) 

(o the circulation of the blood, is fo extremely improbable 
in itfelf, that there are few at this time, who can be 
ignorant or fuperftitious enough to believe it — The gen- 
tleman undoubtedly miftakes the effe£t for the caufe; for it is 
unquestionable, that when the diforder continues long, the 
whole body becomes coloured with biliary matter, internally 
as well as externally : and I well recollect to have alhfted in 
the duTetlion of a woman during the laft winter, whofe liver, 
ftomach, colon and other neighbouring parts, were deeply 
ftained with biliary matter, which appeared to have tran- 
fuded through the gall-bladder, biliary du&s and liver •, but 
upon enquiry I found, that this perfon, was not obferved to 
have any fymptom of Jaundice, during the difeafe, which 
eventually put an end to her life. Now, admitting the fa&s 
adduced to corroborate this theory, is it prefumable that the 
bile would tranfude through the fubftance of the gall-blader, 
before it would be abforbed, or regurgitate into the blood ? 
but two objedions appear to me, to deftroy this opinion, 
i. Bile injeaed into the cavity of the abdomen in a living 
animal kills it in a very fhort time. 2. I am informed, that 
it is by no means uncommon, to fee thofe yellow transfufions 
inperfons who had not died of Jaundice; and the fluid 
which is continually exhaling into the abdominal, cavity in 
the difeafe, is as likely to be coloured with bile, as the 
urine and faliva, without its having paffed immediately from 
the gall-bladder, or any other part of the biliary fyftem. 

Among the caufes which give rife to the difeafe, I mall 
take the liberty to introduce in the catalogue, 

rirft-Inflammation-Hence it is we fo often fee Jaun- 
dice accompanying hepatitis or acute inflammation of the 



( 24) 

the liver — This only happens, however, when the Inflam- 
mation is extenfive, and is by continuity or contiguity of parts 
propagated to the biliary ducts, whofe coats, becoming fwelled, 
and inflamed, clofe their cavities or diminifh them fo much, 
as to hinder the free pafiage of their contents, into the duo- 
denum ; but, that inflammation of the liver often occurs 
without the difeafe, is indifputable — befides an inflammation 
of the liver, it is poflible enough that inflammation feated 
originally in the pancreas, duodenum and other adjacent parts, 
may fpread fo as to find its way into thefe duds, and thus 
occafion the difeafe in queftion — I have heard of two cafes, 
in which it was produced by a tranflation of inflammation. 

A fecond way, by which inflammation may acl in pro- 
ducing Jaundice, is by affording inflammatory exfudations, 
which promote an accretion of the duels, and obliterate their 
cavities ; or elfe ferve as nuclei for fubfequent biliary or 
calculous depofitions, and thus give origin to one of the mod 
common caufes of obftruclion — And it is Iikewlfe poflible, 
that a concretion or coalefcence, of the fides of the duels 
may take place, from a long continued lateral preflure, in- 
ducing fuch a degree of inflammation in them, as to create 
an adhefion ; in either cafe the duels may be partially ob- 
firudled, or become totally impervious. It is extremely dif- 
ficult to afcertain when fuch an accretion is the caufs cf ob- 
ftruclion, and what is more to be lamented, if we knew of 
its prefence, we are in pofleffion of no remedy which will 
remove it — Strictures, I am induced to believe, often re- 
main in the duels after inflammation, and give rife to cafes 
of the mod obftinate Jaundice — Inflammation fometimes, 
tho rarely, manifefts itfelf in thofc parts in the form of ex- 
crefcenccs, which annihilate the cavity of the duels, or 
ftretch them far beyond their ordinary fize. 



( *5 ) 

Secondly — Biliary calculi — Thefe arc, by far, the moil 
toramon caufes of the difeafe — they are called biliary, not 
becaufe they always confift of bile, but becaufe they are ge- 
nerally found in the liver and its appendages — The blood 
and almoft every fluid fecreted from it, by remaining ftag- 
rtant in little manes, lofe their fubtile parts by abforption, and 
become thick and folid ; hence it is, that ftones, or (to 
fpeak more correctly) indurated concretions, are fo often 
difcovered in the body after death ; and in no part of it 
does this happen fo often, as in the liver, gall-bladder, and 
biliary duels, owing, in all probability, to the languid circu- 
lation in the liver, to the particular nature of the bile and, 
in part, to the confinement to which it is occafionally expofed, 
in the gall-bladder and other parts of the hepatic fyftem. 
Calculi are fo commonly fpoken of by phyficians, and 
fo often obferved by anatomifts, that to adduce examples, or 
quote authority, to prove their exiftence, would be fuper- 
fluous and unneceflary. — They are in general inflammable, 
and will fwim in water, but this is not invariably the cafe. 
They differ in firmnefs, from the confidence of honey to the 
mod hard and compact ftone ; their fize is only limited by 
the capacity of the gall-bladder or part in which they form, 
and they are found of every intermediate dimenfion between, 
this and the fmalleft imaginable grain. In colour they vary, 
from that of a pale brown to an intenfe black •, once m a 
while, they are found red, green, tranfparent, Sec. 1 hen- 
form is not lefs variable : they are fometimes fmooth and 
even, at others extremely rough and irregular. In number 
they vary, from one, actually, to many hundreds. Their 
compofition is very different, at different times, and in dif- 
ferent perfons ; mod of them appear to be compofed of the 
conflituent principles Of the bile ; a few, of an ofTeous fub- 
fiance; many white, fteatomatous, or cheefy in their ap- 
pearance •, others, again, appear fabulous, cretaceous, of 

D 



( 26' ) 

gritty, and often exhibit a calcareous fracture. It is not 
likely that bile alone is fufceptible of this variety of appear- 
ance j we muftj therefore, look to fome other fource, in 
order to account for their formation. They appear to me 
to be tributary, for their exiftence, to three principal fources. 
— id, Infpiffated or confolidated bile, indubitably compofes 
the greatell number of them. — 2dly, Effufions of blood or 
coagulable lymph, in confequence of inflammation, may con- 
tribute to their formation, by lodging in the biliary palTages, 
and affording nuclei for the depofition of biliary matter— 
3dly, A morbid fecretion — May we not from analogy con- 
clude, that the liver, as well as other parts in a ftate of dif- 
eafc, may fecrete a fubftance totally diftinct from bile, which 
may, fome how or other, give origin to calculous collections. 
To thefe a fourth caufe has been added : viz. bile coagulated 
in the inteflines, and indigeftible fubftances of any kind, 
forced into the biliary duct from without : but any one ac- 
quainted with the anatomical ftructure of thefe parts, would 
have difficulty in admitting even the poflibility of fuch an 
accident : if we recollect that the duel pafTes fome diftancc 
between the mufcular and villous coats of the duodenum be- 
fore entering it, we mould imagine, that the firft irritation 
would excite a contraction of that inteftine, and completely 
exclude the offending matter. It is eafy to conceive, how" 
calculi or any other obstruction in the biliary ducts may lay 
the foundation of fchirrus, induration, tubercles, and the 
like, in the liver and all the vifcera from which it receives its 
blood ; for from an accumulation of bile in the branches of 
the hepatic duct, the circulation in the liver muft be greatly 
interrupted, and congeftion and inflammation in the abdo- 
minal vifcera inevitably be the refult. 

Thegreateft number of calculi, feem to be generated in the 
gall-bladder, where they often lie concealed for a long time, 



( n ) 

without any confiderable inconvenience ; until by fomc im- 
pelling power, they are thruft into the dut"te — This is an ac- 
cident which often happens from fome violent and fudden 
effort, fuch as vomiting, fneezing, a ftrong fit of coughing, or 
vehement exercife of any kind, driving the calculi, if there 
be any adapted to the orifice of the du£l, fuddenly into it, 
in which, except their tranfit be quick and eafy, they are im- 
pacted and become the immediate caufes of obftruction : This 
we conjecture to have been the cafe, when Jaundice has 
fucceeded fome immoderate exertion of the body. 

It is difficult to afcertain when a calculus is the caufe of 
Jaundice, the moft common diagnoses, however, are the 
following— a pungent pain in the beginning of the difeafe, 
frequent chilly fits, and an inceffant difpofition to vomit— the 
pain which attends, may, in general, be diftinguifhed from 
that which accompanies inflammation of the ftomach and 
inteftines, by the comparative flownefs and natural ftate of 
the pulfe—lf the fize of the calculus, be happily fuch, that 
the diameter of the dud will admit of its palling off, it is 
conveyed into the duodenum, a bilious diarrhoea fupervenes, 
and it is difcharged, to the eminent relief of the patient. 

It fometimes happens, that an adhefion is produced by in- 
flammation, and the done difcharged by fuppuration diredly 
into the ftomach, colon, duodenum, or lungs, and the patient 
recovers; and cafes are related, of their having been dif- 
charged externally, through the integuments in the fame 
way. When they burft into the abdomen the cafe is gene- 
rally fatal. 

We (hall frequently obferve fymptoms indicative of cal- 
culus, when no yellownefs is feen : this may happen, from a 

D 2 



ftone being fo fituated in the duct, and oF'fuch form as not 
entirely to hinder the pafiage of bile. So fhall we obferyc yel- 
lownefs, without any fymptom which would induce us to fuf- 
pect a calculus in the duds, from diftenfion of the duodenum 
or inflammation of the duel: entering it, occafioned by any ir- 
ritating fubftance. In fhort, it may be faid, that the figns of cal- 
culus are very equivocal and uncertain; and it is probable that 
many painful fenfations, which pevfons are wont to refer to the 
lungs, ftomach and other parts of the alimentary canal, will ul- 
timately be found to have their feat in the liver or biliary duels. 

The difeafe by which phyficians are mod commonly de- 
ceived, is colic. People will fometimes be afflicted with a 
permanent colic : by the repeated administration of cathartic 
and anodyne medicines, they will appear cured ; but the dif- 
eafe fhortly recurs and may again be removed, by the fame re- 
medies : — thus they vibrate as it were, for months and fome- 
times years, between indefinite points of eafe and pain, 
until the difeafe appears unmafked and in its own fpecific 
form, when the powers of the medical art are often inef- 
ficient to arreft or prccraflinate its lethiferous career. Thefe 
fymptoms are eafily explained, by fuppofing at the end of the 
common duel, a ftone irritating the mufcular coat of the 
duodenum, which, contracting violently, forces it back into 
the lefs irritable and contractile part of the du£ and the pa- 
rb.xyfm ceafes, until, by the vis a tergo, the calculus is again 
piifhed into the fenfible extremity of the du&, when, the 
attack will be renewed :— thus one calculus may in fome 
inftahces give rife to a dozen attacks of Jaundice, or an hun, 

dred paroxyfms of the moft diftrefling colic in cafes like 

thefe, wc ought always to be upon our guard, to fufpeft 
hepatic difeafe, to prefcribe and predict accordingly— 
when a calculus has become fixed in the duct, the cafe is, 



truly deplorable ; but here it is confolation to know, that 
the difeafe is not perpetual, but alternately coming on, and 
xeceding in regular paroxyfms. As foon as the gall-bladder 
and excretory duds are diftended with bile, parts contiguous 
being irritated by the diftcnfion, naufea and vomiting in- 
tervene, in confequence of which, thefe turgid veflels are 
comprefled on all fides, and the bile not being able to pafs 
through the ordinary road into the inteftines, by the vehe- 
ment preflure which it fuftains, is driven back through the 
fecretory canals, into the ramifications of the hepatic veins, 
by thefe it is conveyed with the blood into the cava and hearc 
itfelf. In this way is the diftended refervoir often dif- 
burdened of its contents : the acute pain, and vomiting ceafe 
for a while, and the patient is aftonifhingly relieved : but 
the formidable career is not yet ended-, the yellownefs will 
gradually difappear, and every thing appear to go on well, 
until the bile accumulates afrefh, then, the deftruftive 
paroxyfm commences again with unrelenting violence; thus, 
the referable fufferer continues fometimes better, fometune, 
worfe, through a long and tedious fcene of diftrefs, unul 
impotent nature refufes to protraft the deadly com, 
bat, and the patient fall, a f.crifica to the com^t; or, 
the vigorous and reiterated efforts of the confhtuuon 
overcome the refiftance, and accompli* the expulfion of the 
ftone. It is almoft incredible, what large (tones wUl to> 
times pafs through the common dud :-from he ddatj 

(tones feveral inches in circumference had pafled d«^ 
Doubts are entertained, whether a ftonein the cyltiC 

L*. it to return, it certainly can, but » no otfc.r way. 



( 3*> 

It has been doubted too, that obftruction in the hepatie 
duct, could produce the difcafe, but, there have been cafe* 
of Jaundice, from indurated and fchirrous liver where the 
larger ducts could not have been affected, which will force 
us to admit it : and is it not probable that partial affections of 
the liver, by preffing on the branches of the hepatic duct, 
may fometimes induce thofe evanefcent fymptoms of Jaun- 
dice which are fo often taken notice of— Yet, I believe, 
by far the moft common feat of the obftruction, is juft at the 
termination of the duct in the duodenum : this is incontro- 
fertibly proven by diffections, and by the acute pain, atten- 
dant on the prefence of gall-ftones, which could arife only 
from the irritation at the inteftine ; for, from the experi- 
ments of doctor Monroe and others it feems, that the ducts 
ihemfelves poffefs no mufcular coat, and but little fenfibility 
or contractile power. 

Thirdly— Spafm— acting fo as to dimintfh, or cut off the 
communication, from the liver to the interlines — whether 
the biliary ducts have pofitively mufcular fibres, and are capa- 
ble of afluming an aftion of the fpafmodic kind, I mall no€ 
take upon me, to afferc •, although, I am difpofed to think, 
that what happens in cafes of fpafmodic Jaundice, may be 
well enough comprehended, by an acquaintance with the 
"mufcular ftructure of the duodenum, without adverting to the 
controveify about the mufcularity of thefe ducts. 

This caufe of the difeafe is always to be fufpected, when 
it occurs fuddenly, without any preceding fign of indifpofi- 
tion ; when it affeds perfons fubjeft to hyfteria, hypochon- 
driafis, and other fpafmodic difeafes ; or fuch as are under 
the influence of violent commotions of mind, and when the 
difeafe difappears, foon after the intermillion of the fpafm. 



<3i ) 

The effe& of violent pafiions of the mind in giving origia 
to Jaundice, is demonftrated by frequent and repeated ex- 
perience in the practice of medicine : nor will this furprife 
any one, in the lead acquainted with the connection which 
fubfifts between the mind and body, and how powers af- 
fecting the brain and nerves, communicate their effects to 
every part of the fyftem — Although thefe effects from 
the nature of their caufes, elude the obfervation of our fenfes> 
(till, they are fo confentaneous to reafon and analogy, that 
we are compelled to acknowledge them. 

Fourthly — InfpifTated mucus, or any vifcid matter whatever, 
Muffing up or clogging the orifices of the excretory duds in 
fuch a manner, as to prohibit the free and eafy paffage of 
bile into the duodenum— 

We (hall not be furprifed to hear of fuch a thing happen- 
ing in the biliary pafiages, when we remember, that, like the 
inteftines, the gall-bladder and biliary du&s, have innume- 
rable villous projections on their internal furfaces : nor fhaU 
we be more at a lofs to underftand, how the quantity and 
Confidence of their mucus difcharge may be fo augmented,- 
or changed, as to retard or hinder the egrefs of bile into the 
inteftines — We (hall be led to fufpect this caufe of Jaundice? 
from the remedies which prove mod beneficial towards its- 
removal ; from the relaxed and debilitated habit of body, 
which is its ufual companion, and from a predominance of 
tenacious phlegm, in the throat, ftomach and bowels : hence 
the origin of the difeafe in infants, called by nurfes the Yel- 
low Gum, which almoft always difappears, as foon as the 
mucus, with which their prim* via; were engorged, is ex- 
pelled from their bodies. 



(3* ) 

A retention of the meconium in infants gives rife to Jaun- 
dice, by mechanically (hutting the entrance of the biliary 4 
duel into the duodenum, or inducing, by its quantity or acri- 
mony, fpafm in the interlines, and thereby preventing the 
admifHon of bile into them. 

This yeliownefs in infants, is afcribed by fome, to an ab- 
sorption of the meconium itfelf — This may fomctimes be the? 
cafe, but that it does not uniformly happen, is evinced, by 
its frequently occurring with bilious diarrhoea. 

It has been remarked, with great apparent confidence, that 
an increafed craffitude or vifcidity of the bile, cannot pro- 
duce Jaundice, becaufe (fay the advocates of this opinion) 
if its confiflence be fuch, as to prevent its pafling through the 
excretory duels, it is hard to conceive, how it mould get 
through the inconceivably fmall orifices of the fecretory or 
lymphatic veflels — I grant, that after the bile has become fo 
infphTated in the gall-bladder and excretory ducts, as to ren- 
der its exit into the duodenum difficult or impoffible, it is 
not to be fuppofed, that it will return to the blood through 
the minute fecretory tubes, which are probably as paflive as 
the excretory du£ls themfelves. But whoever will allow 
himfplf time to recolletl: the facility, with which the abfor- 
tents take up the mofl firm and folid parts of the body, can 
find no difficulty in admitting, that a preternatural fpiflitude 
of the bile, may once in a while, give rife to the complaint ; 
and it is in the higheft degree probable, that the abforbents 
have fome inherent action of their own, which enables 
them to perform their offices more completely, while excre- 
tory veffels are all paffive in their operation — It has been 
urged, likevvife, that circumftances in the hiflory of the dif- 
eafe are repugnant to this opinion— ■The one upon which 



( 33 ) 

mod flrefs is laid, is, that the gall-bladder has been frequently- 
found, after death, in a ftate of great diftenfion from a col- 
lection of thick vifcid bile, yet Jaundice had not been the 
confequence. To this objection, it is anfwer enough to fay, 
that tKe gall-bladder has often been found diftended, with 
more fluid bile, in which the difeafe did not precede death. 

Fifthly— Tumours— efpecially of a fchirrous nature, in the - 
liver, pancreas and parts circumjacent, by their fize or 
fituation compreffing the biliary duels— Examples of Jaun- 
dice from this caufe are taken notice of by all anatomical 
writers — In cafes of fwollen and indurated liver, the difeafe 
is not occafioned by a want of fecretion, (for we are informed 
by very refpeaable authority, that the liver will continue to 
fecern bile in a very difordered ftate) but, by the difeafed 
part, preffing upon the hepatic dud or fome of its ramifica- 
tions, while the reft of it is performing the bufinefs of fecre- 
tion. This will be the cafe when the induration is feated in 
the concave part, or when the conglobate glands, inclofed 
in the capfula Glifibnii, become enlarged. 

Under this head may be confidered, cafes of Jaundice 
which occur during pregnancy, from the prefTure of the 
uterus, or colon diftended with indurated feces >, in which 
the difeafe goes off after delivery as foon as the parts 
are reftored to their original and healthy ftate. 

The difeafe is alfo likely to occur in coftive habits, m 
which cafe, it m^ft be produced by fome of the large in- 
teftines preffing on the biliary dufts, or, (which is more pro- 
bable) by an unufual quantity of bile being confined in the 
inteftfrs and abforbed by fhe la&eal veflel*. 

That all the caufes which have besri enumerated en pre* 

2 



( 34) 

duce Jaundice, will appear evident to every one in the lead 
converfant with anatomy ; and that they have produced 
it, the ditfecUons of Bonetus, Morgagni, and other equally 
diftinguifhed anatomifls, abundantly prove. 

But what fhall we fay of that yellownefs or Jaundice 
(if I am permitted to call it fuch) which is occafionally feen 
in the bilious fever of our country, and efpecially in that 
malignant form of it denominated yellow fever? — I acknow- 
ledge that, in my mind, there exifts not a doubt on the fub- 
jecT:— I am decidedly of opinion that it is owing to bile pre- 
fent in the blood. 

This opinion I the more readily embrace. I. Becaufe it 
occurs in thofe difeafes in which a redundance of bile is fo 
common; 2. and during the feafons principally in which thofe 
difeafes prevail; 3. becaufe, we do not know, for certain, of any 
other way, by which this phenomenon could be produced— 
but any how, it is very certain, that thefe icteric phenomena 
prefent themfelves, with copious difcharges of bile from the 
ftomach and inteltines, a manifefl proof, that the biliary 
du£ts are pervious and clear of obftru&ions. It is by no 
means an uncommon thing, to find perfons during the hot 
feafon, with high coloured urine and a fenfible yellownefa 
in the whites of the eyes, without general fever, but accom- 
panied with bilious vomiting, or diarrhoea ; and perfons con- 
valescing from an attack of ordinary intermitting, or remitt- 
ing fever, fometimes meet us with unequivocal fymptoms of 
Jaundice— It alfo occurs in a fmall degree in thofe complaints 
fo common among us, called inward fevers, and particularly 
in perfons much addicted to the ufe of ardent fpirits. How 
it comes to pafs, that the caufes producing bilious fever, and 
the intemperate ufe of fpirituous liquors, fhouli a (SI in fuch 



( 35 ) 

a manner as to produce this immoderate fecretion of bile, I 
fhall not attempt to explain ; but that they have Tome fpecl- 
fic operation upon the liver, we have the molt unexception- 
able teftimony to prove, or whence happens it that the liver 

is fo uniformly af7ec~led in both cafes ? 1 may here remark, 

that ftarving has produced Jaundice ; it is explained thus ; 
after the abftra&ion of nutrition, the blood continuing to 
move on by the powers of the circulation, is loft principal]/ 
in the fecretions and excretions ; among the reft the biliary 
fecretion continues, and by fome provident effort of the cionfti- 
tution is often augmented ; by which means the bile, pafiing 
In its ufual courfe into the inteftines, is taken up by the latleat 
abforbents, and conveyed into the circulation, where, in con- 
fequence of the diminiftied quantity of blood, it becomes 
perceptible to the fenfes. 

In addition to the more common caufes which produce 
Jaundice, I muft not forget to mention others which are more 
ambiguous in their operation. They are the bites of poi- 
fonous and rabid animals -Contagion -fupprefiion of fome 
cuftomary evacuation — -Repelled eruptions, wounds and frac- 
tures of the cranium , inftances of all which are mentioned 
by medical writers— they may produce the difeafe by induc- 
ing fpafm which is itfelf the caufe of obftruaion, or by fome 
convulfive effort which takes place during the accident, forcing 
infpifFated mucus or calculi from the gall-bladder, into the 
duftus communis choiedochus— but, that neither of thefe 
caufes could have induced it, in feme inftances, would ap- 
pear; from the fudderinefe with which it came on, from its 
having occurred in perfons not fubjea to fpaCmodie d.feaics 
and who had not been expofed to any of the caufes which are 
generally thought to produce fpafm ; and admitting a fpaf- 
siodic afieaiorTof the inteftittes had occurred,, the quantity 

£ 2 



C'3<5 X 

of bile fecretedin fo fhortra fpace of time, could not have 
been fufncient to have contaminated the whole mafs of b'ooc!. 
The only way then in which Jaundice can be produced by 
fuch caufes, is, by fome unaccountable change in the 
circulation, by which means, feme of the conftituent parts 
of the biie are difengaged, exhibiting either partial, oruni- 
verfal phcenomena of jaundice. 



Having taken a view of the caufes which produce Jaundice, 
and their mode of operating, it will be no very difficult talk, 
to give an explanation of the moll common fymptoms obferv- 
able in the difeafe. 

The fenfe of oppreffion, tightnefs, and weight, with the 
pain and anxiety felt about the epigaftric region, generally 
depend upon congestion in the biliary organs, owing prin- 
cipally to an accumulation of bile in the gall-bladder and 
branches of the hepatic du£t, which, preffing upon the rami- 
fications of the blood-vefiels, greatly impede the paffage of 
the blood through the liver — An enlargement of the liver 
from a turgefcence of its vefiels, will account for cpngeftkm 
in the abdominal vifcera, which were formerly in the habit 
of difcharging their blood into the circulation, through the 
medium of the vena port arum— The powers of digeRicn and 
chylification languifli, becaufe they cannot exift in perfection 
without the aid of the bifc \ and the reafen of the emaciation 
and debility, which is fo uuiverfally experienced by i&enc 
patients, mutt be, that the chyle which is formed in the ia- 
tsfcines, is not of the ufual quality, or is fuch, as is iefs cal- 
culated to convey proper nourishment to the body, 

With regard to the torpor, inaeYr/ity and drowGnefs oif 



( 37 > 

difpofition to fleep, which occurs in the difeafe, there is. 
a divifion of fentiment. Some fuppofe thefe fymptoms ow- 
ing to the general affection of the ftomach and bowels, and 
afcribe them to that wonderful fympathy, which fubfifts be- 
tween the alimentary canal and every part of the fyftem, 
obferving, that the inteftines become torpid from the ab- 
tence of the natural ftimulus of the bile, and that this 
torpor or laffitude is diffufed by fympathy over the whole 
body. That fymptoms of proftration, analogous to thefe, 
do occur in certain affections of the ftomach and inteftine* 
cannot be denied j but in the difeafe under confideration, they 
certainly may be accounted for, upon more rational grounds. 
—I am difpofed to believe, contrary to the affertions of mo ft 
writers, that thofe variations in the animal functions, are 
owing, in moft cafes, to a deficiency in the quantity of blood 
fent to the brain— We are taught, that a certain and definite 
degree of tenfion in the veffels of the brain is indifpenfable 
to the due performance of its functions— We know that in 
Jaundice, fanguification rauft be diminifhed, in confequence of 
imperfeft digeftion ; and is it not allowed on all hands, that, 
compreffibn below the heart, on the fyftem of blood-veffels, 
will always have a tendency to induce plethora in the abdo- 
men, thorax, and inferior extremities? for the veins being 
far more comprembie than the arteries, the preflurc in- 
duced on the latter muft be much lefs confideraWe in it* 
effects, than that which is fuftainedby the former: hence it 
is, that afcites, anafarca, and hydrothorax, are fo often the- 
confcquences of vifceral obftruaions : Seeing then, that the 
quantity of blood fent to the brain, is lefs than its ordinary 
fupply, we could not, with any degree of plaufibility fuppofe, 
that thefe fymptoms were Ac confequence* of a compreffed 
brain-And moreover, in Jaundice, refpiration is always 
free and eafy, which is never the cafe when the brain fuffera 



( 33) 

from comprefiion •, but the quantity oP blood may be rela- 
tively increafed in confequence of obllrudion in the liver 
and an abfence of biliary fecretion, in which cafe, the brain, 
in common with the other parte of the body, may fuftain 
injury from plethora. 

The obtufe pain, is always the refult of a diflenfion of the 
gall-bladder and biliary duels, from an accumulation of 
bile ; the acute pain is generally the confequence of inflam- 
mation, whether it be considered the caufe or the effect of 
the complaint ; it may alfo be the confequence of a calculus, 
irritating by its magnitude, or lacerating by its roughneft" 
and irregularity— In Jaundice, occurring in paroxyfms, the 
acute pain about the epigaftric or right hypochondriac re- 
gion, is oftener excited by violent efforts to vomit, than by 
any other caufe, while the ingrefs of the bile into the duo- 
denum being done away, the turgid gall bladder is expofed 
to the moft violent prefTure : and here we fee the reafon that 
iaeric patients oftimes feel the moft excruciating torture. 
At length the bile, by mechanical violence, is repelled into the 
Wood, a temporary relaxation commences and contim 
until congeilion takes place anew, when the painful paroxyfm 
recurs— This alternate accumulation and repulfion accounts 
for the periodical returns of Jaundice, in a very fatisfaftory 
manner: they occur as often as the neceffary collection of 
bile is renewed after a complete obftruaion of the du€k ', 
or as often as newly generated calculi, are fucceffively im- 
pafted in the duds, after the paffage of others into the duo- 
denum. 

The naufea, and vomiting mayeither depend upon prox- 
imity of parts, in confequence of which irritation is com- 
municated to the duodenum and ftomach ; or upon feme 
conneaion exifting between thofe parts/ fimilar to that ob- 



( 39 ) 

ferved, in affections of the kidnies and bladder, which it 
not well understood — Vomiting is always a troublefome 
fymptom, but is a falutary effort of the ceconomy, to relieve 
the liver and its excretories, of their unwelcome and oppref- 
five load — The yellownefs which appears in fome one oc 
every part of the body, as In the eyes, urine, fkin, faliva, 
nails, &c. is owing to the limpid or ferous part of the blood 
being tinged by the colouring matter of the bile — When the 
fkin takes on that extraordinary dark yellow appearance, 
which in fome cafes tends to a livid colour, the dif- 
eafe is abfurdly denominated black Jaundice. The proxi- 
mity of the colour of the (kin to that of a black in a few cafes, 
has led fome to fuppofe that there is fomething peculiar in its 
nature. Among the antients there were fome, who believed 
that it was owing, to fome affection or alteration in the fpleen 
—•Others were fatisfied with an idea, that it was owing to 
an abforption of black bile, fecerned by the capfulse atrabi- 
liariae : but thefe opinions totter, upon the moll fuperficial 
examination ; for, firft of all, this black colour has frequently 
been obferved to occur when the fpleen has been in perfect 
health, and, on the other hand, it is now allowed, that no 
fuch fluid as that called by the ancients atrabilis, is prepared in 
the body. Others again there are, who fuppofe it owing to an • 
organical confumption of the biliary fyftem ; but this fuppofi- 
tion appears to be equally void of foundation : for it undoubt- 
edly very often occurs, where the liver and excretory duels 
have not been more affected than in ordinary cafes of the 
difeafe It is now generally believed, that there is no- 
thing- extraordinary in the difeafe called black Jaundice, 
as to its nature or with a view to its medical treatment ; 
and that it depends entirely on a change in the colour of the 
bile, before or after abforption, from an inveterate duration 
of the difeafe ; perhaps it may be influenced by fome conftw 
tutioaal difference in the perfoa affected. 



{ 4= ) 

The imperfect or depraved vifion, muft depend upon an 
alteration in the humours of the eye, from effufions of bile, 
diminifhing their tranfparency and altering their confidence ; 
of courfe, objects being viewed through a yellow or not 
perfectly tranfparent medium, have a yellow tinge, or are 
feen. indiftin&ly — This depraved vifion feldom occurs, but 
that it fometimes does, is unqueftionably true ; and when it 
does happen, can be owing to nothing but an extravafation of 
biliary matter in the humours, or between the coats of, the 
eye ; which, although invifible to the eye of a beholder, 
may be fo confiderable, as to colour the rays of light in their 
eourfe to the retina. The green appearance of blue objects 
in icteric people, is in all probability occafioned by fome 
accidental combination of colours in the eye which I do 
not thoroughly comprehend — The bile prefent in the faliva 
imparts a bitter tafte to it, and in confequence of this, every 
thing taken into the mouths of jaundiced perfons, is fup- 
pofed by them, to have a bitter tafte ; while, communicating 
its acrimony to the perfpirable matter, it excites a prurient 
or itching fenfaticn on the fkin, which is more or lefs fevere 
according to the greater or lefs acrimony of the bile •, but 
whence it happens, that fome are fo much perplexed by this 
fymptom, whilft others are perfectly exempt from it, is not 
cafily conjectured. The rough, hard and irregular feces, 
depend upon the abfence of the mucilaginous qualities of the 
bile, which in a natural ftate of things, lubricates their fur- 
face, and diminifhes their tendency to cohefion : their more 
putrid odour and white appearance, are brought about by 
the want of the colouring and antifeptic part of the bile. 

Coftivenefs arifes from a defeft of bile, without which the 
inteftines do not perform their ordinary peiiftaltic contrac- 
tion; hence alfo arifes, want of appetite, and loathing of food, 



< 41 ) 

for without the bile the aliment continues longer than or- 
dinary in the alimentary canal and digeflion is impeded: 
hence arife heart-burn, hiccough, acid eructations and fla- 
tulency, all, from an abfence of the antifeptic and other prin . 
ciples of the bile, which are the proper correctors of acef- 
cency. Whenby vomitingorany other caufe, a calculusor other 
ohftructing matter is expelled, a large quantity of bile ruih$s 
into the interlines, and is immediately fucceeded by a bi- 
lious diarrhoea, which is always efteemed a harbinger of 
approaching health. - ' 

The fever which accompanies the other fymptoms and 
often proves fatal to the patient, is either fymptomatic of 
the Inflammation in tke liver and biliary duels, or is occa- 
sioned by the ftimulus of the bile upon the heart and arte- 
ries, which it excites into ftronger and more frequent con- 
tractions. If Jaundice continues long (fay fome) the blood, 
from the great proportion of bile in it, degenerates into a 
thin watery fluid, which, by reafon of its tenuity, tranfudes 
with eafe through the exhalents into the cells of the cellular 
membrane, collects in the greater cavities of the body and 
gives origin to dropfies of the mod incurable kind. — But 
although the blood has in a few inftances been found dif- 
folved and uncommonly thin, I think it more probable, that 
the hydropic effufions which occur in ob&inate cafes of Jaun- 
dice, are either the confequences of an impediment to the 
return of blood through the afcending cava, or cf the fymp- 
tomatic fever which accompanies the difeafc. The dyfpncea, 
firiaure acrofs the breaft, palpitation of the heart, irre- 
gular or intermitting pulfe and uneafinefs or darting ia fleep, 
are ©ccafioned by a colle&ion of water in the thorax dii 
niihing its cavity and confequently comnrefling the heart 
andx lungs. 



( 42 ) 

PROGNOSIS. 

The termination of Jaundice is precarious, and the event 
will always be different, according to the nature of its caufe» 
the violence of the fymptoms, the age, conftitution and 
other circumftances of the patient. If the difeafe hath come 
on fuddenly in ftrong and vigorous conftitutions, is recent 
and its fymptoms mild, it is feldom of extenfive duration, 
and the probability is generally in favour of a recovery. la 
cafes, where the difeafe is imagined to originate from fpafm, 
or from mucus plugging up the biliaty pafiages, as indicated 
by the age, difpofition or temperament of our patient, the 
prognofis is for the moll part favourable. The lighter or paler 
the yellow colour of the fkin, the more favourable in general 
will be the iffue of the difeafe : the nearer it is approximated 
to black the greater is the danger to be apprehended. 

Should bile be ejected by vomiting, and the (tools con- 
tinue nearly of their natural colour, if digeftion goes on tole- 
rably well, and the patient lofes ftrength but flowly, we need 
not fear a fatal termination. A bilious diarrhoea is always 
favourable. 

A Jaundice fucceeding or accompanying a fever is an 
eauivocal fymptomj the fooner it occurs in the difeafe the 
more favourable ; and the longer the duration of the 
fever which it fucceeds, the more dangerous — When many 
and violent fymptoms appear; the fasces are white and dry 
without indications of the prefence of bile in the inteltines ; 
digeition flow and imperfect ; the paroxyfms of the difeafe 
frequent and painful ; the alvine difcharge copious or colli- 
quative ; the abdomen hard and tumined with great lofs of 
ftrength and emaciation, the difeafe is in a fair way to end 



( 43 ) 

anortally. If drcpfy intervenes with dyfpncea, palpitatron, 
vermicular and intermitting pulfe, he&ic fever, with third 
and anxiety, particularly when the patient is advanced in life 
or of an infirm conftitution, the cafe is ftill more alarming. — 
When the fymptoms are complicated and not well marked, 
we fhould give our prediction in ambiguous or evafive terms ; 
for it will often happen that fome of the moft mild, and pro- 
mifing fymptoms, will be combined with others, the moft 
malignant and fatal; neverthelefs, I believe, we may give our- 
fefes a greater latitude than is generally allowed -, for a brig 
continued obftruclion to the outlet of bile, has not fuch per- 
manent ill effects, nor do they prevent the recovery of the 
patient after the obftruclion is done away, fo long as is 
generally imagined : and there are not wanting inftances, 
where Jaundice has returned frequently for many years, in 
which the perfon enjoyed good health all the time, in the 
intervals of the attacks. 

CURE - . 

In this, unlike moft other difeafes, it is impoffible to 
lay down any one general plan of treatment, which will b~ 
found to hold good indifcriminately. 

The nature and power of the remedies to be ufed, will de- 
pend much upon the ftate of the fymptoms, the caufe of the 
difeafe, and the condition of the fyftem. 

If inflammation has given rife to it or there exifts 
a full, hard or tenfe pulfe, pain, heat, thirft and other fymp- 
toms of general fever— Blood-letting, and the antiphlogiftic 
regimen, are to be had recourfe to without hefitation or re- 
ferve. The times when ic will be neceflary to repeat the 

F 2 



( 44 5 

operation, arc only to be afcertained by an attention to the 
violence of the fymptoms, and particularly, to the date of 
the pulfe — Cathartics, emetics, and fudorifics mould be 
ufcd as auxiliaries to the lancet — Acidulated, diluent and 
demulcent drinks are of confiderable utility and ought not to 
be omitted. The languor 2nd debility accompanying Jaundice 
would feem to point out that evacutions were improper, 
but experience happily convinces us that the reverfe of this 
is true ; and it is by evacuations alone that we have an op- 
portunity of fubduingthe fymptoms •, nor is the patient fo much 
reduced by the effects of depletion, as by the continuance of 
the difeafe--Should the pain continue obltinately fevere, af- 
ter the judicious adminiftration of the remedies juft recom- 
mended, tepid emollient fomentations to the epigaftrium, 
and the warm bath, with occafional opiate anodynes are ad- 
mifTible and proper. In fome inftances it may even be pro- 
per to ufe opium and the lancet in conjunction, as will be the 
cafe when, from a calculus or any other caufe, inflammation 
exifls in the duels with a fpafmodic conflriction cf parts in 
their vicinity. 

When Jaundice arifes from fpafm, in perfons fubject to 
fpafmodic difeafes or in fuch as have been expefed to ac- 
cidents, which have been known to produce in them fymp- 
toms of convulfion; opium, amber, vitriolic tether, afa- 
fectida and other medicines defignatedby the epithet an- 
tifpafmedic, will often give inflantaneous relief— perhaps 
dulling cold water in large quantities upon the patient might 
have fome good eftecl:. 

When the difeafe is fufpe&ed to depend on a fuperabun- 
dance of vifcid mucus, or any other tenacious matter infarit- 
feg the excretory dafls; occurring in the phlegmatic tempera- 



(45 ) 

mcnt or during the period of infancy, fap&nacsptis Mid di- 
luent medicines with the occafional exhibition of purgatives 
and emetics and afterwards tonics," are all that will in 
general be necefiary — But 

If the obflru&ion depends upon gall-ftones in the biliary- 
duels, the cure is much more difficult; though their expul- 
fion is fometimes effected by the unamfced efforts of nature. 
It has been ascertained by melancholy experience, that bi- 
liary calculi yield much lefs to the articles denominated 
lithontriptics, than thofe which are generated in the urinary 
organs; it would however be right to give fome of them a 
trial in every inveterate cafe. 

The chief and mod celebrated among the folvents for bi- 
liary calculi, are, the cauftic alkali, foaps, faline foiutions, 
itrong mineral acids, oil of turpentine, decoctions of com- 
mon grafs, the juices of fucculent plants and fpirit of wine. 
Dr. Heberdcn pcfitively declares, that in many experiments, 
inftituted to difcover folvents for biliary concretions, he -was 
not fo fortunate as to find any thing that would diffolve 
them. But admitting they were foluble in any of thefe fub- 
ftances out of the body, (which is aiTerted by fome) it is 
plain that a dircd application cf them to calculi in the 
biliary paffages is wholly impracticable, if in the inceft'mes, 
they are foon voided by ftool and render the interpoudon 
of medical afiiftance unneceffary; and when we reflect on 
the courfe fuch articles muft take in the circulation, before 
arriving at the liver, in crder to mix with and medicate the 
bile in fuch a manner, that it may a6l as a folvent on thefe 
calculi, the difficulty of introducing a {efficient quantity of 
them, is felf CTidenjt. It is therefore extremely .doubtful 
whether any real benefit has ever refuiteu from their q 



(4* ) 

lition, except what mightmorejuPJybejattriiiuted'tc their deob« 
ftruent effects ; by which, they, to a certain degree, compenfate, 
for the abfence of the bile, which they refemble in promoting 
digefrion, and in preferving order and regularity in the bowels* 
As it is not likely that any thing taken into the body, will 
in the lead facilitate the folution of gall-Ptones while they 
are in a fituation to do harm to the conilkution, our princi- 
pal exertions ought to be diredled to their expulfion. With 
this intention, the firft indication fhould be, to induce, as 
far as with Safety may be done, relaxation: In the next 
place having rendered the du£fc pervious by the (tone, we. 
fiiould caufe the patient to make fome violent exertion o£ 
his own with a view to expel it. In order to bring on a pro- 
per degree of relaxation, no remedy feems better calculated, 
than vensefection; the quantity of blood to be taken, muft be 
regulated by the age, conftitution and fituation cf the pa- 
tient, above all, by the exigencies of the cafe, and the ft ate 
of the fyfiem ; after bleeding, the patient may take mucila- 
ginous and diluent drinks, have emollient and laxative enc- 
mata oecafionally injected ; and fomentations applied to 
the abdominal region. After thefe remedies have been ufed 
Sometime, wc fhoukl attempt the evacuation of the (tone, by the 
repeated ufe of emetics and purgatives. — It is obferved by fe- 
veral refpe&ablc practitioners, that after the operation of vo- 
mits in this difeafe, biliary concretions have often been found 
in the ftools of their patients, and they may do effential fer- 
vice by difioging from the biliary paflages a large quantity of 
vifcid humour. If vomiting gives great pain it ought not to be. 
repeated, but purges fubftituted in its place with the occa- 
sional ufe of anodynes — what would be the effed of fub- 
jecling the patient to the relaxing influence of a warm bath, 
whiie under the operation of an emetic ? from its efficacy in 
the reduction of Strangulated hernia, and in removing obfti- 



(47 ) 

rate conflipation, might we not expect advantage from fuch 
a practice ? 

If fchirrous induration of the liver, or any part in the vif- 
cinity oi the biliary duCts, hath given origin to the difeafe, 
Sanger 35 to be apprehended, and unlefs a long continued 
and regular courfe of mercury have an effect in relieving 
the iymptoms, we may defpair of effecting a cure •, for the 
difcuflionof indolent fchirrous tumors is always difficult, and 
too often impofiible— In the word of cafes, however, medi- 
cine is capable of affording relief, and it would be un- 
grateful in the extreme, to abandon our patients over 
to the arms of death, while there remains the fmalleft hope 
of a recovery— Palliatives mull therefore be reforted to j 
fuch as cordials and anodynes, — the mineral waters, fomen- 
tations and laxatives; by the feafonable and judicious ad- 
miniftration of which, we may often allay, or obviate fome 
of the moft diftreffmg fymptoms of the difeafe— The volatile 
alkali, cicuta, and aether, are faid to have been inftrumental 
in the cure of Jaundice from this caufe ; and I think it not 
improbable that blood-letting, in particular gojoiUtutions or 
ftates of the fyftem, might be practifed with advantage. 

If the retention of the meconium in children ffiould at 
any time be the caufe, by creating obftrudion at the orifice 
of the common duet, the exhibition of fome gently laxative 
medicine, will very foon check its prcgrefs, but Jaundice 
will fometimes continue in children, after the ftomach and 
inteftines" are perfedly cleanfed, perhaps owing to the vifci- 
dity which the unabforbed bile acquires by ftagnating in the 
biliary duels. 

On the cure of thofc icteiitious fymptoms occafioned by 



( 48 ) 

the bites of venomous animals, fractures cf the cranium, &c» 
I have nothing to fay ; the remedies here, as in all other 
cafes, mould be accommodated to the nature of the caufe, 
and the ftate of the fyftem. 

In all cafes it will be cf the utmoft confequence, to keep 
the bowels lax and regular 5 mercury though fometimes 
ufeful, fnould in ordinary cafes be abftained from, unlefs it 
be given as a cathartic ; and unripe fruits, as having a ten- 
dency to augment the fecretion of bile, mould be avoided : 
The diet of the patient fhould be nutritious, eafy of digeftion 
and fuch as is leaft difpofed to become acefcent •, his repafls 
fhould be frequent, and in fmall quantities, wi:h diluent and 
demulcent drinks -, moderate exercife wiil be ferviceable when 
he is in a ftate to bear it without fatigue or inconvenience — 
If, in the courfe of the difeafe, he mould become much re- 
duced and debilitated, the ufe of ftimulating, tonic, or corro- 
borative medicines, muft be fled to without delay to fupport 
and invigorate the patient. It is of importance, to give fome 
cathartic medicine with opium, to obviate its aftringent ef- 
fect's upon the inteftmes. Blifters are fometimes ufed in the 
difcafe, but they rarely give permanent relief. 

Specifics upon fpecifics for Jaundice, have a long time 
degraded the writings of medical practitioners : to name 
them only would be offering indignity and difgrace to the 
fcience which I profefs— But in our times, fince days of 
founder philofophy have illuminated the world, and phyficians 
nave learned to take more expanded views of the human 
conftitution, we have with pleafure beheld thofe children of 
ampofture rapidly depreciating •, and the time, I know, will 
yet arrive, when thefe impious boafts of ignorance and fupcr- 
ftition, will be as much ridiculed and dstefted, as they were 
tonce venerated and adored. 



(49 ) 

Perfons convalefcing from Jaundice, or fuch as are liable 
to frequent returns of it, fhould be extremely vigilant, and 
religioufly refrain from every fpecies of intemperance — Ex- 
pofure to the unwholefome exhalations of a polluted atmos- 
phere, and the ufe of ardent fpirits, ought to be ftudicufly 
and abftemioufly avoided — Many, from the nature of their 
employments and fituations, are unavoidably expofed to va- 
rious irregularities; others voluntarily plunge themfeives 
anto the mod unnatural excefTes : thefe gentlemen would. 
<do well to reflect, what foes they have to encounter, and the 
«difiicultv attending the re-eftablifhment of health after once 
having loft it ; indeed, from the combined effects of climate, 
iituation and their ov/n deleterious conduct, too much can- 
not be apprehended : and. how wretched mull be the exist- 
ence of that being, who is conftantly tortured by the pains 
of difeafe, and whofc only moments of eafe, are procured by 
the reiterated application of medicine. Health is doubtlefs 
the firft and bed of all temporal bleffings, without it our 
choiceft pleafures become odious and tirefome— the animal 
anachme dwindles into puerile and enervated effeminacy — 
Honour and opulence become vague and infignificant titles, 
and life itfelf an unremitting focjw wf ™lC*r Y *nd dittrefs. 
Thefe are confederations, which ought to teach mankind the 
value of health, and make thofe who poffefs it, (eduloufly 
ftrive to cherifli and preferve it. 

« The firft phyficians by debauch were made, 

« Excefs began, and {loth fuftains the trade : 

« By chace cur long-liv'd fathers earn'd their food, 

« Toil ftrung their nerve-, and purified their blood," 



The reader is requeued to CQYYtZl the following 
ERRATA. 

In page 4, line 11, for thefe, read thefes. 

7, 1 7, for confift, read confifts. 

8, 14, for deodenum, read duodenum^ 
3f 5", 23, for froms, read from. 

18, 5, for directty, read dire&ly. 

21, 25, for inftrumentatily, read inftrumentality.' 
Idem, 1, for feperation, read feparation L 

29, *, for truly, read truely.